Last night on "ABC World News," Diane Sawyer and Dr. Richard Besser delivered a tough critique of those breast-screening guidelines that the federal government pushed late last year. The ABC report was plenty tough, leading the broadcast, but still not tough enough, because while Sawyer and Dr. Besser refuted the government's effort to ration breast-screening, they didn't go further and tell us why the government wants to ration such care--and why even after this rebuke, the government will likely try again.

Sawyer began: "Less than a year ago, you'll remember a government panel said women do not need regular mammograms till the age of 50." Now, she continued, a new study of one million Swedish women found that "mammograms in your 40s can dramatically save lives from breast cancer."

Then she turned over the segment to Dr. Besser, who added that he sent the Swedish study to 24 doctors and cancer specialists around the country; 21 of them, he said, were already telling their patients just that--get checked regularly in your 40s, don't wait till age 50. Besser added that the screenings could cut deaths from breast cancer by 26 percent; saving the life of 1 out of every 1200 women screened. He concluded, "Today's study flies in the face of those controversial government recommendations last year when a panel found mammograms for women under 50 should be an individual decision, rather than a general recommendation."

The original recommendation from a government panel, the US Preventive Services Task Force, which came to light on November 16, 2009, should not be seen as a scientific recommendation--they were a political recommendation, aimed at giving the Obama administration, and the overall cause of healthcare rationing, a boost. We're spending too much on healthcare, the larger argument went, and besides, much of our healthcare spending is counterproductive--so why don't we spend less and call it a win-win?

Those recommendations caused such a firestorm last year that they were withdrawn--or where they? In a bureaucracy, nothing ever dies. Bureaucrats wishing to advance a particular position might have to make a tactical retreat every so often, but they never give up.

So the original finding should not be seen as an isolated incident. There will be more. The bean counters and rationers--here at Serious Medicine we call them Scarcitarians--will be back. They have not in any way given up in their efforts to define American healthcare downward.

But there is hope, if the people are made aware of their own interests. And the media, too. Interestingly, while the politics of the Mainstream Media are firmly on the side of the Obamacare rationers, the ratings eyeballs are to be found on the opposite side of the argument--the Serious Medicine side. People want to know about how they can stay alive, and they will reward TV networks that help them in that perfectly understandable goal. It's real people, after all, who consume all the medical information in the larger culture; it's only a few policy wonks who think just the opposite--that people should have less information, and less access to care, pursuing, as they do, their "less is more" vision.

They are less interested in saving the government money in the shortest of short runs. In the long run, of course, we would be better off, financially as well as medically, if breast cancer were reduced and then eliminated.

Thursday, September 23, 2010

“Health Care: Booster Shot for Jobs?” is the title of a new post by Michael P. Scott, an associate with the Denver-based urban consulting firm Centro, appearing in NewGeography.com. I agree with everything about Scott’s title--except the question mark. As his piece makes clear, healthcare is a booster shot for jobs.

Scott starts with a paradox: Why it is that cities and their economic-development officials so often ignore the bird in the hand (the palpable reality that lots of people work in healthcare) in favor of the more speculative, perhaps even non-existent bird in the bush (the jobs to be found by luring in tourist attractions). As Scott puts it:

The local medical center complex is often the largest employer in town, it would seem that strong fiscal returns would be rewarded to those cities that strategically aligned their economic development efforts to capitalize on growing this sector. Unfortunately, the health industry has historically been viewed as a local disaster, replete with quality of care issues, bureaucratic inefficiencies and high costs.

As noted here many times at SMS, the dominant policy classes in Washington and New York, plus satellite nodes in Cambridge, San Francisco and elsewhere, have concluded that economic growth is great--but not in healthcare. In healthcare, as we know, we have to “bend the curve” downward. To be sure, these “Scarcitarian” elites wrap up their arguments in statistics, but as far as I can tell, this is basically an aesthetic judgement these elites are making: we spend too much, and so we should spend less.

But of course, aesthetics often makes for poor economics. In this case, it means that the policy elites wish to provoke a recession in the healthcare sector even as they seek to “stimulate” the economy out of the recession. Given that healthcare is one-sixth of the economy, it’s a challenge to shrink such a huge component while seeking to enlarge the overall whole; and, as we have seen, policymakers have not been very successful in this hit-the-healthcare brake-while-hitting-the-macro-accelerator approach.

But the mantra of cutting healthcare, no matter what the cost, has been heavily programmed into these policymakers, so they keep going, and going, and going, even when they are no longer making policy.

Typical of this persistence is a recent post from Peter Orszag, the former director of the Office of Management and Budget in the Obama administration until last month. Just a few days ago, he published a blog-post for The New York Times, in which he linked cuts in healthcare to not only the cause of deficit reduction, but also to increases in take-home pay and even improvement in public education:

Containing health care costs is not just an abstraction central to addressing our long-term fiscal gap. It is also central to raising workers’ take-home pay, because increasing costs for health care are holding down wages. And perhaps most unexpectedly, slowing the growth of health costs may be among the best things we can do to help the next generation attend a high-quality public college.

But as Scott laments in his post:

Little attention is given to health care jobs as springboards to enliven local and regional economies. The steady parade of doctors, nurses, technicians and support staff at our medical establishments provide cities with a huge multiplier effect on nearby housing, restaurants and retail businesses. The trickle-down effect spreads outward to hospital manufacturers, suppliers, pharmaceutical companies, and other ancillary firms that serve as the lifeblood of a functioning health care system. The economic activity of the medical business extends well beyond hospital walls; it's a high-octane job engine, with the buying power of health professionals helping to sustain struggling communities.

But unfortunately, as Scott describes, cities with big healthcare complexes ignore those healthcare complexes, the bird in the hand, in favor of speculative new stadiums and museums. As Scott describes the situation in Cleveland:

Cleveland, Ohio, is a prime example of a city that has undermined its economic potential by permitting dubious redevelopment efforts – centered on sports complexes and museums – to overshadow assets such as the Cleveland Clinic and the University Hospitals Health System, which together encompass 51,000 employees.

Like most Rust Belt cities, Cleveland sorely needs an infusion of jobs outside of the long diminished blue collar sector. It could build collaboratively on its health care niche, creating complementary clusters of medically related firms in the life sciences and health information systems that would bring new opportunities and life to the area. The city's world-class medical establishments could supply the ideal springboard for branding Cleveland as a global medical hub, rather than as the home of the Cleveland Cavaliers and the Rock and Roll Hall of Fame museum.

One Cleveland-area organization, BioEnterprise, is taking the lead in fueling the growth and commercialization of health care companies in the bioscience sector. A collaborative effort between top medical and higher education institutions in the region, BioEnterprise is a promising attempt to alleviate Cleveland's persistent difficulties in generating jobs and economic growth.

Scott further notes that these are good jobs at good wages; nationwide, the average salary is $43,000. And Scott describes efforts to use health care as an economic engine in cities as different aOakland, Sacramento, and Spokane. He concludes:

When cities and regions choose to create synergies between their communities and their medical campuses, the prognosis is promising for an economic cure.

And oh, by the way, in addition to the economic benefits of healthcare, there are other benefits, too, that one can’t get from another urban galleria.

Tuesday, September 21, 2010

The Kaiser Family Foundation has released a new animated video, narrated by Cokie Roberts, touting--they would say “explaining” but I maintain that “touting” is a more accurate verb--Obamacare.

Let me begin my review of this new video by saying I am all in favor of using new tools to communicate dense policy information. We should be using videos and texts and tweets and anything else we can think of to better communicate policy. If we do, there’s every reason to believe that policy literacy will rise--as the Pew Foundation noted recently, consumption of news is actually rising, as people now find their news on new platforms, such as PDA’s. So the KFF deserves credit for pushing the envelope of imagination.

However, it’s just as easy to put a distortion, or worse, into the new media as it is into the old media. And that’s what we see early on in the nine-minute KFF video, at about the :40 mark, when narrator Roberts says, “Polls show about three out of ten of us say health care reform will make us better off, a similar number say worse off, and a similar number again say it won't make much difference at all. Some of us don't know what to think. I guess you could say we’re kinda split on this one.” Well now, that’s a pretty optimistic take on public opinion, in keeping with the strongly pro-Obamacare tone of the whole video.

Yet as lots of anecdotal information tells us--most notably, the special-election victory of Scott Brown to replace the late Edward M. Kennedy in the US Senate--the preponderance of evidence suggests that Americans are much more anti-Obamacare than pro-Obamacare. And yet none of that is included in the video. Thus so the KFF video gets off on the wrong foot, using an assertion that is at best misleading.

Next, Roberts’ narration takes up the issues that the Obamacare legislation purports to deal with, starting with the cost of healthcare:

Let’s begin with the problems in our current health care system. Problem number one is, what problem number one usually is, money. Most people agree that health insurance policies are too expensive. For a family, the average premium is almost $14,000 dollars a year...and growing. Premiums have doubled over the last nine years, ballooning way faster than inflation! Plus, our population is aging, meaning more people with more health problems. So, health care costs are the fastest growing part of the federal budget.

In the minds of the KFF video creators, that’s an open-and-shut matter of fact: The biggest single issue in healthcare is the cost of care.

But is that really the case? When you go to the doctor, do you talk to the doctor about finance? No. You talk to the doctor about your health--what hurts, what’s not working, what might even kill you. For their part, doctors go to medical school to learn the art of healing, not the art of financing. At best, healthcare finance is a means to an end--the end is better health.

But as noted here in the past at SMS, over the past 40 or so years, doctors and medical scientists have been dethroned from their place at the pinnacle of our healthcare system, replaced by a combination of public- and private-sector financiers. And these financiers have persuaded Washington DC, at least, that the real issues in healthcare are financial. In other words, financiers have sold the political elite on a vision of healthcare that is not unlike the financial vision of everything else in the country. Everything is a financial issue, and if you hire the right bean-counter, backed up, of course, by a Wall Street “quant,” then every problem can be solved. Or if the problem can’t be solved, well, at least the financiers make money. This “financialization” of everything is a problem everywhere, but it has deformed healthcare policy, to the point where healthcare experts, such as those at KFF, tell us that the issue is medicine is not medicine, but finance. Perhaps the KFF’s roots, amid Kaiser Permanente, the big managed-care conglomerate are starting to show. Such a pro-financialist bias might be perfectly understandable, but that doesn’t make the bias more accurate.

But let’s not ignore the bureaucrats, and their role. As narrator Roberts tells us, the other problem of healthcare that needs to be solved is the problem of access to health insurance:

The second problem is that the system is full of holes. Like the fact that people buying insurance on their own can be turned down for having a pre-existing health condition. Small businesses may be charged extra if some of the workers are sick, making insurance unaffordable. And some insurance policies have a lifetime limit on benefits. After that, you’re out of luck. That means some of the people least likely to have coverage are the ones who need it most.

And so once again, we see the increasing influence of non-doctors, in this case, social-science-oriented policymakers and the bureaucracy. If financiers have demoted doctors, so have social scientists. As a result, we have a healthcare system dominated by financiers--including for-profit hospital executives, who seem to spend more time worrying about investor relations and their own bonuses than they do about patients and wellness--and bureaucrats. And so it shouldn’t be surprising, then, that we are told that cost and access are the number one and number two issues facing healthcare.

So what’s number three on the KFF list? Actually, there is no number three. Echoing, once again, the arguments of Obamacare, the KFF video stops at those two issues: cost and access. The goal of healthcare, according to the Obama/KFF mindmeld, is to hold down the cost and ensure universal access. We can imagine a company that saw itself as providing a cheap product to all customers. Never mind whether or not the product was good, the goal is that it is cheap, and that everyone could get it. Such a company, of course, would not likely stay in business for long, but as we know, the government, as well as richly endowed private foundations, have their own ways of doing things.

For any discussion of research and cures, well, you’ll have to go somewhere else, other than this video. Those two words, “research” and “cures,” literally do not appear in the video, just as they have fallen out of the discussion in Washington. And none of us--not even the financiers and bureaucrats--are better off for it.

Monday, September 13, 2010

In its lead editorial on Sunday, The New York Times editorial page makes a strong argument for Comparative Effectiveness Research (CER), the process--part scientific, part budgetary, part political--by which the government and other entities decide how effective medical drugs might be, and whether or not they are worth the cost. In theory, CER makes good sense, but the sine qua non of CER is trust. That is, we must be able to trust the people doing the CER, because our lives are at stake.

Yet if we don’t trust the “CERites,” as we might call them--that is, if we, the American people, were to conclude that the CERites are just another opaque, unaccountable, and arrogant group of bureaucrats, operating according to a different agenda than public health--then the whole CER system breaks down.

For its part, the Times asks us to trust CER as implemented by the Obama administration; indeed, the Times wants to turn the CERites loose, giving them far greater power than they have at present.

Under the headline, “Is Newer Better? Not Always,” the Times makes a series of points: First, the newspaper concedes that the prime driver of healthcare costs is better technology, and it freely admits that such improved technology is oftentimes a good thing. But new technology is not always better--that’s the second point. And then, third, the paper falls back on a familiar refrain, that the real issue in healthcare is keeping costs under control. As the Times editorial puts it:

The Congressional Budget Office estimates that an astonishing half or more of the increased spending for health care in recent decades is due to technological, surgical and clinical advances. For the most part, such advances are a cause for celebration. But an expensive new drug is not always better than an older, cheaper drug, and sometimes a new technology or treatment that is highly effective for some patients is unnecessary or even dangerous for others. The system almost seems designed to keep driving up costs.

We might dwell on that last line, on costs. Controlling healthcare costs has been a major preoccupation of the liberal left for decades now; touting the “cost-cutting measures” thenabout-to-be-passed healthcare bill in March, President Obama himself declared: “My proposal would bring down the cost of health care for millions--families, businesses, and the federal government.”

There’s nothing wrong with bringing down costs, of course, but the method by which those costs are to be controlled matters a great deal. Many of us believe, for example, that a line-ahead emphasis on cost-cutting in healthcare is counterproductive, for two main reasons: first, such cuts are extremely unpopular with voters, so that the cost-cutters are likely to be ex-cost-cutters; second, and more profoundly, the easiest healthcare cuts to make in the short run are those that don’t involve helping people directly and immediately, e.g. the speculative research that might lead to a cure. And so the immediate desire to cut spending, with little regard for the pain, or the backlash, gets in the way of a more patient determination to cut spending by improving health. In other words, the cost-cutters, going for the fiscal equivalent of immediate gratification, never solve the real issue of healthcare, which is the chronic mismatch between the demand for healthcare and the supply of healthcare.

Yet the Times editorialists are not Luddites; they recognize that sometimes new inventions--everything from the wheel to the assembly line to a smart phone--can, in fact, drive down costs. As they observe,

Even costly therapies can end up saving money as well as lives. Studies by respected economists have shown that spending on new cardiac treatments, neonatal care for low-birth-weight infants, and mental health drugs have more than paid for themselves.

But then the Times cites examples that it sees as wasteful and costly:

Consider the prostate-specific antigen test, which is widely used to screen men for possible prostate cancer. In an Op-Ed piece in The Times in March, Richard J. Ablin, the doctor who discovered prostate-specific antigen, described the test as “hardly more effective than a coin toss” at distinguishing who is at risk, and lamented that the test’s popularity has led to “a hugely expensive public health disaster. Each year some 30 million American men undergo the test at a cost of at least $3 billion, and many go on to have surgery, intensive radiation or other damaging treatments that may not have been necessary.

Dr. Albin, through his achievements, has earned a respectful hearing for his views, but others have differing views--starting with the approximately 200,000 American men diagnosed with the disease every year. Indeed, well-regarded voices in the debate, such as the National Cancer Institute (NCI), a unit of the National Institutes of Health, don’t seem to agree with Dr. Ablin. On its website, NCI acknowledges that prostate testing is “controversial,” but in discussing that controversy, NCI cites findings that tend to contradict Dr. Ablin, such as a European study that found that testing led to a 20 percent reduction in deaths from prostate cancer. Such is the nature of a scientific debate, still very much in flux. (By the way, the NCI site offers a list of seven speculative treatments--seven different ways, a fiscal pessimist might say, to spend money, or, alternatively, as a medical optimist might say, seven different ways to hopefully defeat prostate cancer.)

But what’s perfectly clear is that men with concerns about prostate cancer--and that category should include men over 40 with a family history and every man over 50--are going to want to seek out their own answer, with their own doctor. Government diktat is not popular on matters of life and death; one needn’t fear the specter of “death panels” to nonetheless fear bureaucratization of life-and-death decisionmaking.

In fact, the picture of CER, in practice, as opposed to theory, is distinctly mixed. The Times hightlights the work of the Dartmouth Atlas of Health Care, one of the central texts of the CER movement, which purports to show gross cost-differentials in hospitals across the country, not connected to efficacy or good results. But in fact, twice now in recent months now, in February and in June, the Times has attacked the quality of the Dartmouth data, pointing out that the Dartmouthians made elementary mistakes--or, more likely, omissions:

But the atlas’s hospital rankings do not take into account care that prolongs or improves lives. If one hospital spends a lot on five patients and manages to keep four of them alive, while another spends less on each but all five die, the hospital that saved patients could rank lower because Dartmouth compares only costs before death. “It may be that some places that are spending more are actually getting better results,” said Dr. Harlan M. Krumholz, a professor of medicine and health policy expert at Yale. Failing to receive credit for better care enrages some hospital administrators. But for the Dartmouth researchers, making these administrators uncomfortable is the point of the rankings. “When you name names, people start paying more attention,” Dr. Fisher said. “We never asserted and never claimed that we judged the quality of care at a hospital—only the cost.”

That’s an interesting admission--if that’s the right word--in the last paragraph: that the Dartmouthians never claimed to be judging the quality of healthcare in their mapmaking. Once again, this article ran in the Times just three months ago; we can be sure that the Times editorialists read it, the question is why they didn’t refer it.

One major source for Dartmouth critiques is a piece appearing in the February 17, 2010 New England Journal of Medicineby Dr. Peter B. Bach, “A Map to Bad Policy--Hospital Efficiency Measures in the Dartmouth Atlas,” also not mentioned by the Times editorialists. One might think that if the Times editorialists are going to praise Dartmouth, then the paper of record at least ought to note the many criticisms and controversies surrounding the Dartmouth data.

Also not mentioned in the Times editorial is the role of the pioneering CER agency, National Institute for Health and Clinical Excellence (NICE), part of the United Kingdom’s National Health Service (NHS). To put it mildly, both NICE and NHS are lightning rods in the UK as well as the US. A sample headline from a major British newspaper reads, “Sentenced to death on the NHS: Patients with terminal illnesses are being made to die prematurely under an NHS scheme to help end their lives, leading doctors have warned.” Yet the Times editorializers didn’t mention of that CER work, either, even though we know that top Obama healthcare officials, such as Dr. Donald Berwick, head of the Center for Medicare and Medicaid Services, has been open in expressing his admiration of UK-style CER.

Indeed, here in the US, we are already seeing the direction in which Obama-style CER, powered by the same mindset as Dartmouth and NICE, is headed. Last month, Serious Medicine Strategy took note of recent moves by the Obama administration to eliminate federal approval for the anti-breast cancer drug Avastin, on the ground that it costs too much, despite its demonstrated efficacy. The headline atop the editorial page of The Wall Street Journal last month got right to the point: “The Avastin Mugging.”

It’s not possible to settle here the debate over the right way to treat breast cancer, any more than it is possible to settle the debate over prostate cancer. But by the same token, it also won’t be possible for the federal government, either, to settle these debates--because people don’t trust the feds. And so CER is effectively crippled, because people don’t trust the motives of CERites. In a democracy, the government doesn't get far, not fo long, without the consent of the governed.

Unfortunately, the Times editorial didn’t address any of those legitimate concerns, nor even report on the controversies.

As noted at the beginning of this piece, CER depends on trust. CERites are the would-be equivalent of Platonic Guardians in the medical world. To borrow the famous critique of Plato by the Roman poet Juvenal, who asked of Plato's idea, "But who will guard the guardians?"we can ask, in our time, “Who will mediate the medicators?” Because while CER is a good idea, in theory, it sure seem as if the CERites, and their editorializing advocates, need to be closely mediated, in practice.

Friday, September 3, 2010

It’s noteworthy that of the 67,000 new jobs created in August, 28,000 were created in the healthcare sector--that’s 42 percent of the total. Intuitively, we know healthcare is a natural economic engine--we have an aging population, desirous of more medical services. And all that cash sitting on the sidelines, waiting to buy something worth buying!

Indeed, since most affluent countries around the world share the same graying demographic, so if the US had wanted to, we could have expanded our healthcare sector to better serve the world--and thereby expanded jobs on the homefront.

In other words, we could be seeing a lot more job growth in the health sector than we are. And yet curiously, the Obama administration spent the first 14 months of its existence pushing for healthcare insurance, which, by its own declaration, was aimed at reducing costs--that is, shrinking the healthcare sector. As Obama himself said in July 2009, his “bottom lines” were two: “Does this bill cover all Americans? Does it drive down costs in the public and private sector over the long term?”

Despite Obamacare’s best efforts at rationing--which, admittedly, are just getting started--healthcare is still a growth sector. But US healthcare is much smaller today than it would have been if the natural forces driving its growth had been encouraged and channeled toward productive technological improvement, e.g. better medicine and cures. If Obama had gone that Hamiltonian route, his healthcare plan would, of course, have been much different--and much more popular. And, in addition, it would be driving a much stronger economic recovery.